Jurnal THT 2019

M a n a g e m e n t o f E p i s t a x i s in
C h i l d ren an d A d o l e s c e n t s
Avoiding a Chaotic Approach
Peter Svider, MD*, Khashayar Arianpour, BS, Sean Mutchnick, MD
KEYWORDS
Epistaxis Nosebleed Nasal packing
Transnasal endoscopic sphenopalatine artery ligation
Juvenile Nasopharyngeal Angiofibroma (JNA)
KEY POINTS
Obtaining a comprehensive patient history may be useful in evaluation of patients with
epistaxis, although timely management takes precedence for patients with significant
and brisk hemorrhage.
The differential diagnosis associated with epistaxis encompasses a wide range of etiol-
ogies, ranging from benign causes such as digital trauma and foreign bodies to life-
altering entities including systemic hematologic disorders, locally destructive tumors,
and sinonasal malignancies.
The mean age at presentation is 7–9 years, and non-accidental trauma should be ruled out
in children under two years of age.
Epistaxis is controlled with conservative measures including application of topical decon-
gestants, holding pressure appropriately (pinching the nostrils shut against the nasal
septum) in the majority of cases. Chemical cautery and deployment anterior nasal packing
are easily attainable skills and can be used by pediatricians, emergency physicians, and
healthcare professionals as next line management. The trajectory of nasal packing
deployment (aiming posteriorly towards the nasopharynx rather than superiorly towards
the skull base) is critical for effective hemostasis.
Implementation of standardized protocols involving otolaryngology consultation for mini-
mally invasive endoscopic surgical management of recalcitrant epistaxis has demon-
strated promise in reducing morbidity and cost at select centers, although further study
is needed to clarify use in children.
Juvenile nasopharyngeal angiofibroma is a vascular sinonasal tumor presenting exclu-
sively in adolescent males. This should be ruled out in adolescent males with unilateral
nasal obstruction and epistaxis.
Financial Disclosures and Conflicts of Interest: None.

Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of
Medicine, 4102 St. Antoine, 5E-UHC, Detroit, MI 48201, USA
* Corresponding author.
E-mail address: psvider@gmail.com
Pediatr Clin N Am 65 (2018) 607–621

https://doi.org/10.1016/j.pcl.2018.02.007 pediatric.theclinics.com
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608 Svider et al
Commonly considered a minor nuisance by the lay public, epistaxis in the pediatric
population harbors the potential for life-threatening hemodynamic instability and
can present in a variety of settings. Significant hemorrhage may indicate serious un-
derlying etiologic factors in select cases, making appropriate management and the
understanding of when to pursue further workup of paramount importance. The differ-
ential diagnosis associated with epistaxis encompasses a wide range of etiologic fac-
tors, ranging from benign causes, such as digital trauma1,2 and foreign bodies,3,4 to
life-altering entities, including systemic hematologic disorders,5 locally destructive tu-
mors, and sinonasal malignancies.6–8 Although similarities exist on comparison with
adults, numerous pathologic factors unique to children and adolescents must be
considered; for example, epistaxis in infants and toddlers merits consideration of non-
accidental trauma or hematologic disorder, whereas certain neoplasms, such as juve-
nile nasopharyngeal angiofibroma (JNA), occur exclusively in adolescents (Box 1).9–11
This article aims to provide an organized foundation that facilitates the management of
acute epistaxis, as well as an understanding of features that merit further diagnostic
workup.
Box 1
Differential diagnosis of epistaxis in the pediatric population: common considerations
Primary (idiopathic) epistaxis

Secondary epistaxis
Congenital
Arteriovenous malformation
Hemangioma
Inflammatory
Wegener
Systemic lupus erythematosus
Allergic
Allergic rhinitis
Infectious
Acute or chronic rhinosinusitis
Upper respiratory infection
Traumatic
Digital trauma
Septal perforation
Foreign body
Nasal instrumentation (ie, nasogastric tube, nasopharyngeal airway)
Nasal bone fracture
Septal fracture
Nasoorbitoethmoid fracture
Iatrogenic
Medication (anticoagulants, nonsteroidal antiinflammatory drugs)
Toxin
Illicit drug (snorted)
Neoplastic
Rhabdomyosarcoma
Lymphoma
JNA
Nasopharyngeal carcinoma
Hematologic
Idiopathic thrombocytopenic purpura
Von Willebrand disease
Hemophilia
Hereditary hemorrhagic telangiectasia
Pediatric Epistaxis 609
HISTORICAL AND EPIDEMIOLOGIC CONSIDERATIONS
My plan is not only effectual, but is easy of application and absolutely painless,
and can be probed in the smallest patients. The little device which I use is
made of fifteen of the longest threads of patent lint.it is passed back upon the
floor of the nasal cavity and pushed on till you reach the posterior nares.then
slowly withdraw the probe and plug the anterior nares and you have arrested
the bleeding.In persuading children to submit to the operation, I often pass
the lint up my own nose to satisfy them it gives no pain. If lint is not at hand, I
use the largest size spool cotton.
—W.W. Parker, MD, 189012
Although the past century has witnessed myriad technological innovations, princi-
ples for the initial management of acute epistaxis remain unchanged. On failure of
conservative measures, such as anterior pressure, standard management includes
deployment of nasal packing, a seemingly innocuous intervention that may prove
challenging in the face of poor patient cooperation or brisk bleeding. The past 2 de-
cades have witnessed the development of absorbable packing materials, precluding
the need for packing removal,13 and advances in optical technologies have further
facilitated minimally invasive endoscopic approaches in cases requiring surgical
management.
Children with epistaxis mainly present between 2 and 10 years of age, with
questionnaire-based and population-based analyses reporting the mean age of pre-
sentation is 7 to 9 years.14,15 More than half of children older than 5 years of age
have experienced at least 1 nosebleed.16 One analysis of nearly 20,000 patients pre-
senting to emergency departments reported that 6.9% ultimately required proced-
ures, almost all of which included simple cauterization or packing.15 In contrast,
only a small fraction (<1%) required surgical intervention. Surgical ligation has been
associated with decreased length of stay among patients who require inpatient hos-
pitalization,17 although further studies exclusive to children and adolescents may bet-
ter help delineate its role. Importantly, implementation of standardized protocols
involving minimally invasive surgical management of recalcitrant epistaxis has demon-
strated promise in reducing morbidity and cost at select centers.18 In the contempo-
rary health care environment characterized by growing consciousness of the costs
interventions have on health care delivery, treatment paradigms may change in com-
ing years. Nonetheless, conservative treatment followed by simple bedside cauteriza-
tion and/or packing remains the mainstay of epistaxis management.
OVERVIEW OF PATHOPHYSIOLOGY
A diverse array of etiologic factors and risk factors can promote epistaxis (see Box 1).
Primary (ie, idiopathic) epistaxis comprises most cases.16,19 Dry environments lacking
humidification can lead to dried nasal mucosa20,21 and associated fissuring of
mucosal surfaces, subsequently leading to desiccation and exposure of blood ves-
sels. Almost all bleeds stem from the rich anastomotic area of vessels located on
the anterior nasal septum (Fig. 1). Bleeding can also originate elsewhere, including
from the lateral nasal wall (as opposed to the nasal septum, which is medial), partic-
ularly the branches of the sphenopalatine artery. Posteriorly, bleeding can stem from
posterior branches of the sphenopalatine artery, Woodruff plexus, and venous
sources.
Any conditions that cause coagulopathies or platelet disorders, including systemic
hematologic conditions and hematologic malignancies, lead to a greater risk of more
frequent and more severe episodes. Specifically, recurrent episodes or a family history
610 Svider et al
Fig. 1. Sagittal section depicting arterial contributions of Kiesselbach’ Plexus on the anterior
nasal septum.
of excessive bleeding should prompt further consideration of von Willebrand disease.

(See Jorge Di Paola and Christopher J. Ng’s article, “Von Willebrand disease:
Diagnostic Strategies and Treatment Options,” in this issue.) Other considerations
are immune thrombocytopenia and hemophilia.22 (See Stacy E. Croteau’s article,
“Evolving Complexity in Hemophilia Management,” in this issue.) Notably, greater
than half of patients with von Willebrand disease experience epistaxis. Other second-
ary etiologic factors should also be considered.19,23 Patients with allergic rhinitis and
chronic rhinosinusitis have a higher incidence of epistaxis.20,21 These etiologic factors,
along with upper respiratory infections, promote inflammation and subsequent hyper-
vascularity of nasal mucosa.16,24,25 Systemic factors can greatly increase the risk of
developing epistaxis. Connective tissue and inflammatory disorders that lead to de-
rangements in the formation of the walls of blood vessels increase vulnerability to
epistaxis. Numerous medications, including anticoagulants, significantly increase
the risk for epistaxis. Iatrogenic trauma, either from surgery or placement of appli-
ances (nasogastric tubes, nasopharyngeal airways), can traumatize blood vessels
anywhere in the nasal cavity. Traumatic facial injury, including nasal bone fracture
or septal fracture, may present with significant epistaxis. Sinonasal neoplasms may
present with epistaxis. Although rare, missing these lesions can lead to devastating
impacts on morbidity and mortality; therefore, understanding when to pursue further
diagnostic workup is critical. Rhabdomyosarcoma is the most common pediatric sino-
nasal malignancy; in addition to presenting with epistaxis, this lesion can spread to
adjacent sites, including the orbit, skull base, and elsewhere in the head and neck
region.6 JNA presents exclusively in adolescent boys, usually presenting with unilat-
eral nasal obstruction, epistaxis, and a mass involving the pterygopalatine fossa-
nasopharyngeal area (Fig. 2).26,27
DIAGNOSTIC CONSIDERATIONS
Timely management of acute epistaxis takes precedence over exhaustive workup. For
cases in which bleeding has stopped, as well as among patients experiencing recur-
rent or chronic epistaxis, several diagnostic steps should be considered. At a
Fig. 2. Adolescent presenting with nasopharyngeal angiofibroma. Coronal computed to-

mography scan (bone window, left panel) depicting left-sided nasal mass. Endoscopic
view (right panel) of nasal septum, located on left, and JNA, located posteriorly along floor
(grayish mass). (Courtesy of W. Hsueh MD, J.A. Eloy MD, Department of Otolaryngology–
Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ.)
minimum, without delaying care, vital signs and a complete blood count should be ob-
tained during an acute episode with further consideration for a basic metabolic panel,
prothrombin time, and partial thromboplastin time. Imaging is not indicated in initial
evaluation, even on suspected nasal fracture. Nasal fractures are a clinical diagnosis
made on history and physical examination (see later discussion) and radiographs har-
bor little to no value. If a significant likelihood of additional facial fractures (eg, orbital or
midface injury) is suspected, then a computed tomography (CT) scan without contrast
should be ordered for stable patients. Contrasted CT, MRI, and angiographic studies
are considered with recurrent bleeds or other findings suggestive of a neoplasm or
vascular entity, such as visualization during endoscopic examination (see Fig. 2). Ge-
netic testing may be indicated for select cases in which there is a family history for an
inherited disorder or associated physical findings that suggest a particular entity (see
later discussion). The differential diagnosis for epistaxis is illustrated in Box 1.
PATIENT HISTORY
Obtaining a comprehensive patient history can be useful in evaluation of patients with

epistaxis, although timely management takes precedence for patients with significant
and brisk hemorrhage. When the epistaxis started, what the patient was doing when it
started, and other inciting factors should all be taken into account. For example, facial
trauma involving significant epistaxis suggests a high likelihood of nasal fracture,
which is ultimately a clinical diagnosis not requiring ancillary tests such as radio-
graphs.28 When bleeding has already stopped on patient presentation, finding out
which side the patient noticed the bleeding is helpful. Other components of the history
that provide valuable insight into the underlying etiologic factors include whether the
patient is on any blood thinning medications, past medical history (including details
about prior episodes), past surgical history, a list of medications, social history
(including snorting of illicit substances), and the presence of a family history of
bleeding or systemic disorders. Among patients for whom this is a recurrent problem,
learning what time of the year they experience epistaxis should also be considered.
Importantly, learning about the interventions patients have undergone or what they
have done for their epistaxis should be determined. For example, if a patient with
epistaxis reports that it is not controlled with holding pressure on their nose, the pa-
tient should be asked to demonstrate how and where they hold pressure to determine
whether they are doing so correctly (Fig. 3). Finally, it is important to rule out
612 Svider et al
Fig. 3. Correct and incorrect strategies for holding nasal pressure to control epistaxis.
nonaccidental trauma,29–31 a scenario considered in patients younger than 2 years old

because spontaneous epistaxis is exceedingly rare in this cohort.16
PHYSICAL EXAMINATION
Vital signs and assessment of airway status should be completed in the initial survey of
a patient presenting with epistaxis. Following this, appropriate physical evaluation en-
compasses a full head and neck examination with obvious focus on the nasal cavity. In
many situations, detailed evaluation of the nose is not feasible while active bleeding is
ongoing and control of hemorrhage is prioritized. In other instances, the bleed may
have slowed and there is an opportunity for evaluation. During examination, the avail-
ability of a reliable light source and an appropriate suction apparatus is essential.
Topical agents, such as neosynephrine or oxymetazoline, should be sprayed into
the nose and anterior pressure should be applied and held, pinching the nostrils firmly
onto the septum, for several minutes. These maneuvers can significantly slow or stop
any bleeding and allow for a thorough examination.
Anterior rhinoscopy can be performed with an otoscope or, alternatively, a nasal
speculum in conjunction with a light source. Most spontaneous nosebleeds stem
from blood vessels located on the anterior nasal septum in Little area, also known
as the Kiesselbach plexus. In epistaxis following facial trauma, it is critical to rule
out a nasal septal hematoma because these can become infected and lead to subse-
quent cartilage destruction and long-term deformity.
Although most bleeds stem from the anterior nasal septum, identification of a pos-
terior bleed can have important implications for management because posterior
packing, or even surgical intervention, may be required (see later discussion). Fiber-
optic endoscopy can be used to evaluate for a posterior source of bleeding when an
obvious anterior source is not identified via anterior rhinoscopy (Fig. 4). Numerous
reports have demonstrated this skill is easily taught and transferrable to health
Fig. 4. Physician using fiberoptic endoscopy to perform transnasal endoscopy. (Courtesy of

Mutchnick S, MD, Detroit, MI.)
care professionals.32 Importantly, flexible fiberoptic endoscopes are universally

available in emergency departments because these instruments are used by anes-
thesiologists and otolaryngologists for upper airway evaluation and fiberoptic intu-
bation. If there is access to an endoscope, it is gently advanced posteriorly into
the nasal cavity, maintaining the tip of the scope on the nasal floor and avoiding con-
tact with structures such as the nasal septum, inferior turbinate, and middle turbi-
nate. The nasal septum, in particular, can be especially sensitive. The exit point of
the sphenopalatine artery can be evaluated, as well as the Woodruff area (the naso-
pharyngeal plexus) posteriorly because this is the most common posterior bleeding
source.33 Endoscopy can also be used to identify other less common etiologic fac-
tors facilitating epistaxis, including sinonasal tumors and telangiectasias, the latter of
which can be a sign of a systemic disorder such as hereditary hemorrhagic telangi-
ectasia (HHT).
In addition to a thorough nasal examination, the remainder of the head and neck ex-
amination can reveal important features guiding management. Palpable cervical
lymphadenopathy should prompt consideration of occult malignancy because head
and neck cancers drain to these lymph nodes. A thorough oral cavity examination is
warranted because other signs of systemic disease can be noted. For example, pete-
chiae can suggest thrombocytopenia, whereas HHT patients may have oral cavity tel-
angiectasias. The otologic examination may reveal hemotympanum, whereas a cranial
nerve examination may reveal deficits that could lead to further investigation of certain
etiologic factors; for example, paresthesia in the distribution of the maxillary division of
trigeminal nerve may be indicative of certain sinonasal neoplasm, a consideration also
brought up among patients with proptosis or deficits in extraocular movements. Peri-
orbital ecchymoses, nasal swelling, and external nasal deviation are consistent with
nasal fracture in the setting of trauma. Of course, these symptoms and findings
following direct nasal trauma clinically define a nasal fracture, and further imaging is
not warranted to confirm this. Importantly, facial and nasal radiographs are obsolete
in this era and provide no additional value for confirming a nasal fracture. Of course,
other concerns in the setting of trauma and epistaxis, such as a patient who sustained
a severe impact or is experiencing hypophthalmus, malocclusion, new onset pares-
thesias, extraocular movement restriction, or other cranial nerve deficits warrant
614 Svider et al
further workup in the form of a facial CT scan without contrast to rule out other frac-
tures. Findings outside of the head and neck may also provide insight. Ecchymoses
elsewhere and signs and symptoms of a joint bleed may suggest a hematologic dis-
order. Furthermore, it is important to conduct a thorough survey to rule out signs of
nonaccidental trauma.
NONSURGICAL MANAGEMENT
Although underlying etiologic factors certainly influence long-term management, prior-

ity is given to stopping hemorrhage and stabilizing the patient presenting with acute
epistaxis, rather than performing a comprehensive diagnostic workup. Management
includes making sure pressure is held in the appropriate location and pinching the
nostrils closed against the anterior nasal septum (see Fig. 3). A common pitfall is hold-
ing pressure on the bridge of the nose, which does not provide pressure anywhere
useful. Spraying of a topical decongestant into the nasal cavity (directed at
the septum), such as neosynephrine or oxymetazoline, may potentiate the impact of
holding appropriate pressure. Pressure should be held for a minimum of 10 minutes
before checking to see whether this has slowed the bleed and, meanwhile, the physi-
cian can take the opportunity to obtain a patient history or pursue ancillary tasks, such
as a blood draw to obtain a complete blood count and possible coagulation factors. In
conjunction with vital signs and monitoring clinical status, these laboratory tests can
identify derangements in coagulation and guide fluid resuscitation, as well as the
administration of blood products, including whole blood, platelets, cryoprecipitate,
fresh frozen plasma, and vitamin K, as appropriate.
After holding pressure, if bleeding has stopped or slowed sufficiently to allow for thor-
ough examination of the nasal fossae, an attempt is made to identify prominent or
bleeding vasculature on the anterior nasal septum that can be easily cauterized with
topical silver nitrate. Importantly, use of silver nitrate cautery on both sides of the nasal
septum in the same location can cause septal perforation and should be avoided.34 If
bleeding has not been controlled at this point, or if it has been controlled but the patient
has a frequent or severe recent history of epistaxis, the next step customarily involves
deployment of nasal packing, although recent paradigm shifts suggest more aggressive
movement toward minimally invasive endoscopic surgery in select cases.
With appropriate knowledge of nasal geometry, nasal packing can be deployed by
emergency department physicians, pediatricians, otolaryngologists, and other physi-
cians and health care professionals (Fig. 5). It is important for individuals to appreciate
that the nasal cavity actually leads posteriorly to the nasopharynx (rather than superi-
orly) (see Figs. 1 and 5). Choice of packing materials can be organized into absorbable
and nonabsorbable, with the latter requiring removal in a follow-up appointment 5 to
7 days later. Greater consideration should be given to absorbable packing in patients
with a higher risk of recurrent epistaxis, such as those with bleeding diatheses or tak-
ing blood thinning drugs. When placing packing, it is important to have the following
available: a working suction apparatus, a light source (either headlight or an assistant
holding a pen light), a nasal speculum, and forceps (preferably bayonet forceps)
(Fig. 6). The nasal speculum can be used to expand the nostril, and the packing should
be placed aiming straight back (not superiorly) along the nasal floor (see Fig. 5). This
technique is appropriate for stopping anterior-based nosebleeds and, depending on
packing, can help with posterior epistaxis in certain instances. After successful
deployment of nasal packing, a patient can be observed for a short period in the emer-
gency department or outpatient setting, if there is no further bleeding. There is no indi-
cation for inpatient observation if the patient is stable and has laboratory tests that are
Fig. 5. Correct and incorrect (dotted lines) trajectories for placement of nasal packing (fore-
ground). Nasal packing placement as viewed from inside the nose (inset, upper right); the
viewing physician is deploying the nasal packing.
normal. Traditionally, prophylactic antibiotics (first-generation cephalosporins or pen-

icillins) have been prescribed for the duration of planned packing placement to prevent
superinfection and toxic shock syndrome, although this practice is not supported by
contemporary literature. Recent prospective trials and systematic reviews have
demonstrated a paucity of evidence supporting this practice.35,36 Nonetheless, pre-
scription of prophylactic antibiotics while packing in place remains standard practice
at many institutions.
Another important consideration for classifying epistaxis that carries significant
implications for management relates to the blood vessels responsible for the
bleeding. Although almost all bleeds stem from the anterior blood supply, a small
proportion of cases involve posterior-based epistaxis. Consequently, conservative
measures and packing techniques aimed at controlling anterior epistaxis may not
be effective, necessitating posterior-packing or even surgical management (see
later discussion). When not controlled with anterior packing, a posterior bleed
should be suspected and an otolaryngologist should be consulted in institutions
with otolaryngology coverage. There are several commercially available packing de-
vices intended for posterior bleeds, many of which use an inflatable balloon to allow
for pressure along the choanae. In settings where such devices are not available, a
Foley catheter can be used with the balloon inserted past the choanae and into the
nasopharynx. The balloon is then inflated and the entire device gently pulled ante-
riorly to make sure it is secured. Any contact such devices have with the nostrils
anteriorly should be protected with padding to prevent alar necrosis, a preventable
616 Svider et al
Fig. 6. Commonly used materials in the management of acute epistaxis. (First column, from
top down) topical spray (oxymetazoline), nasal speculum, suction tip, and bayonet forceps.
(Second column) Rapid Rhino Nasal pack, nasal pack, Bioabsorbable Pack, posterior nasal
pack with balloon port, silver nitrate cautery applicator, and nasal dressing.
complication that may necessitate considerable reconstructive surgery.37 Patients

with a posterior pack require close monitoring with pulse oximetry, usually in an
intensive care unit, due to the potential for activation of the nasopulmonary reflex,
which can cause severe arterial hypoxemia and subsequent mortality. Despite
several studies suggesting that these findings may be anecdotal,38,39 intensive
care unit or stepdown monitoring for patients with posterior packing remains stan-
dard practice in most institutions.
The utility of embolization in epistaxis has been examined in several settings,
although trials focusing on pediatric subjects are limited.40 Embolization is increas-
ingly considered in specific etiologic factors associated with uncontrolled hemor-
rhage, such as in patients with sinonasal tumors. This modality also has utility in
preoperative optimization of select vascular tumors, such as JNAs.10,41 Embolization
may be considered in cases with intractable bleeding or in patients who are unable to
undergo general anesthesia. Despite the minimally invasive nature of this intervention,
there are several challenges to consider, including radiation exposure, limited avail-
ability in smaller institutions, and increased costs. Furthermore, embolization of the
ethmoidal arteries is contraindicated because these are derived from the ophthalmic
artery and occlusion can cause blindness.42 There is also a risk of unintentional embo-
lization of the internal carotid artery and ophthalmic artery.
MINIMALLY INVASIVE SURGICAL MANAGEMENT
Historically, surgical management of epistaxis has involved several approaches,

including those requiring sublabial (upper gingival) incisions to approach the internal
maxillary artery and facial incisions to approach the ethmoidal arteries. With the refine-
ment of endoscopic technologies, minimally invasive transnasal control of epistaxis
has been increasingly performed and is now considered regularly in severe and recur-
rent epistaxis. Transnasal endoscopic sphenopalatine artery ligation (TESPAL) is
routinely performed at many institutions, and epistaxis stemming from other sources
(including the ethmoidal arteries) can be endoscopically addressed. Although these
procedures can be performed with local anesthesia and sedation, the significant
bleeding many patients are already experiencing necessitates general anesthesia
and intubation for airway protection. These procedures do not involve any external in-
cisions, can be done on an outpatient basis, and do not result in a considerable
amount of pain. There have been myriad studies demonstrating adequate postopera-
tive analgesia using nonopioid medications in patients undergoing endoscopic sino-
nasal procedures.43–45
In addition to utility in particularly severe or recurrent epistaxis, several centers have
explored endoscopic epistaxis control to minimize the morbidity and discomfort asso-
ciated with nasal packing. Physicians at the University of Pittsburgh explored the
implementation of a clinical care pathway using TESPAL for epistaxis not controlled
with conservative measures and anterior packing.18 Implementation of this algorithm
decreased costs, length of stay, and days of packing. Other cost-effectiveness ana-
lyses have demonstrated TESPAL is cost-saving first-line therapy for patients with
posterior epistaxis (ie, episodes not controlled with simple anterior packing).46,47
These cost-effectiveness analyses and algorithms exploring the use of minimally inva-
sive surgical management have been studied in adults, and further exploration of their
use exclusively in children and adolescents is warranted. Furthermore, there has
been controversy on whether exposure to general anesthetics has long-term impact
on neurocognitive development in children,48–50 and these potential risks must be
considered in the decision-making process.
SUBSPECIALTY COLLABORATION
The appropriate role of subspecialty consultation differs based on underlying etiologic

factors and clinical setting (Table 1). In patients for whom systemic inflammatory
or connective tissue disorders are suspected, collaboration with rheumatology may
be invaluable for identifying a specific diagnosis and subsequent management.
Similarly, in patients for whom entities involving specific organ systems are suspected,
subspecialty referral is essential; for example, in HHT, seeking evaluation from gastro-
enterology, pulmonary, and neurology or neurosurgery colleagues is critical for iden-
tifying involvement of these organ systems. In patients with hematologic disorders,
including those with coagulopathies, platelet disorders, and hematologic malig-
nancies, close collaboration with a pediatric hematologist is important for long-term
management.
618 Svider et al
Table 1
Suggested management of epistaxis for physicians in various settings
Inpatient or Emergency
Intervention Outpatient Pediatrics Department Physician Otolaryngologist
Pressure X X X
Decongestants (Topical) X X X
Anterior Packing X X X
Silver Nitrate Cautery X X X
Nasal Endoscopy — X X
Blood or Reversal Agents — X X
Posterior Packing — X X
Endoscopic Ligation — — X
Recurrent Epistaxis — — Xa
a
For controlled acute bleeds, recurrent epistaxis can be generally worked up and managed via
outpatient otolaryngology referral for most stable patients.
Otolaryngology consultation should be considered for the successful management

of patients with severe, recalcitrant, and recurrent epistaxis. Familiarity with appro-
priate conservative management, including the correct way to deploy nasal packing,
may be sufficient for addressing most bleeds without expert consultation. Otolaryn-
gology consultation is warranted in patients with recurrent, severe, or posterior-
based bleeds, as well as in those in whom there is early consideration of minimally
invasive endoscopic ligation. All otolaryngologists should be comfortable in the diag-
nosis and management of epistaxis, including employment of conservative measures
and surgical management. Fellowship-trained pediatric otolaryngologists have sub-
specialty training dedicated to the unique considerations specific to the pediatric pop-
ulation. Fellowship trained rhinologists focus on minimally invasive treatment of the
nasal cavity, paranasal sinuses, and anterior skull base, including endoscopic man-
agement of sinonasal and skull base tumors.
SUMMARY
Prompt management of acute epistaxis takes precedence over comprehensive

diagnostic workup. A standardized approach should include conservative measures
such as holding pressure and using nasal packing. Severe, recurrent, and posteriorly
based bleeds should prompt consideration of alternate interventions and expert
consultation, particularly because the importance of minimally invasive endoscopic
intervention has increased in recent years. Although most episodes stem from idio-
pathic causes, consideration of secondary etiologic factors is important in select
cases.
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M a n a g e m e n t o f E p i s t a x i s in

Peter Svider, MD*, Khashayar Arianpour, BS, Sean Mutchnick, MD

Financial Disclosures and Conflicts of Interest: None.

Pediatr Clin N Am 65 (2018) 607–621

Primary (idiopathic) epistaxis

HISTORICAL AND EPIDEMIOLOGIC CONSIDERATIONS

of excessive bleeding should prompt further consideration of von Willebrand disease.

Fig. 2. Adolescent presenting with nasopharyngeal angiofibroma. Coronal computed to-

Obtaining a comprehensive patient history can be useful in evaluation of patients with

nonaccidental trauma,29–31 a scenario considered in patients younger than 2 years old

Fig. 4. Physician using fiberoptic endoscopy to perform transnasal endoscopy. (Courtesy of

care professionals.32 Importantly, flexible fiberoptic endoscopes are universally

Although underlying etiologic factors certainly influence long-term management, prior-

normal. Traditionally, prophylactic antibiotics (first-generation cephalosporins or pen-

complication that may necessitate considerable reconstructive surgery.37 Patients

MINIMALLY INVASIVE SURGICAL MANAGEMENT

Historically, surgical management of epistaxis has involved several approaches,

The appropriate role of subspecialty consultation differs based on underlying etiologic

Otolaryngology consultation should be considered for the successful management

Prompt management of acute epistaxis takes precedence over comprehensive

1. Bequignon E, Teissier N, Gauthier A, et al. Emergency department care of child-

5. Mittal N, Naridze R, James P, et al. Utility of a paediatric bleeding questionnaire

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